=Third Stage.=
1. Fork 32 128 2048
B. C. 45 15
A. C. S 20 30
The typical diagnostic points in third stage catarrhal deafness are: 1.
Tone for the 32 fork is lost. 2. There is an inverted bone-air ratio
for the medium fork. The drum is retracted and the malleus fixed. 4.
The whisper may be heard at less than one foot or not at all. 5. The
Ingersoll watch is heard less than six inches from the mastoid. 6.
Paracousis Willisiani is present.
For the general practician this is important because he can make a
rather definite prognosis.
=Treatment.=—The treatment will be given briefly because space would
not permit of lengthy discussions of details of methods and technic.
FOOT NOTE—Note that the patient hears the tone of the low fork, that
the 128 fork has its bone conduction slightly increased (30 to 35)
that the air conduction is slightly decreased (90 to 70) and that the
high fork remains normal.
A careful examination should be made for some source of focal infection
about the nasopharyngeal tract. Chronic or subacute tonsillitis,
pharyngitis or sinuitis or root abscess are often a cause, and not much
will be accomplished in improving the otitis media until these focal
infections are found and properly treated. The original cause of these
focal infections may have been some bony lesion, but to successfully
correct such lesion now does not mean that the source of infection will
be removed.
Auto-intoxication from gastro-intestinal disease is common. In my
cases, 80% of the third stage have chronic constipation or other
chronic gastro-intestinal affection.
In many severe acute affections of the nasopharynx the inflammatory
process has left the Eustachian tube occluded or stenosed and the
pharyngeal fossa filled with adhesive bands. It is not uncommon to find
the epipharynx and pharyngeal fossa filled with partially atrophied
adenoid tissue or if the curet method has been used for removing
adenoids, there is often connective tissue adhesions and any or all of
these may prevent the normal ventilation of the tympanic cavity by way
of the Eustachian tube.
In such cases surgical removal of these obstructions and dilation
of the tube is necessary. My practice has been to give a general
anesthetic (nitrous oxide or somnoform will be sufficient in many
cases) and by means of an adenotome (La Force or Cradle, I never
use a curet) remove all adenoid tissue. Then by means of the finger
I carefully remove any adenoid tissue in the posterior nares and
pharyngeal fossæ that the adenotome may have failed to get and also
dilate the pharyngeal portion of the tube by inserting the finger.
This operation if carefully and thoroughly done and if preceded and
followed by the proper surgical cleanliness and supportive treatment,
will when indicated, accomplish excellent results. The after treatment
is even more important because if this is not well done, no results
or even unfavorable results may occur. The after treatment consists
of daily irrigations of the nasopharynx, thorough attention to upper
thoracic, cervical and mandibular lesions, aspiration of the Eustachian
tubes and other local treatment to the nasopharyngeal membranes. After
the operation has been done it is best to do no digital manipulation
of the pharynx for from three to six days. After this time digital
treatment, gentle dilation of the Eustachian orifice to maintain its
patency, stretching of the soft palate to reestablish proper nerve
function and the application of deep pressure in the pharyngeal fossæ
to stimulate the otic ganglion is important. This treatment is not
massage in any sense but definite, purposeful, manipulation and if
carefully done will be followed by excellent results.
Since the origin of this method of treatment, there has been much
comment on its value and many have tried or at least they thought
they tried it with unfavorable results. The causes of failure are,
attempting treatment in cases impossible of cure, or poor diagnosis,
improper technic of operator or incomplete operative procedure and
inefficient supportive treatment.
It must be understood that not all cases of otitis media even in the
beginning stages require the above method of treatment or will be
benefited by it. Those cases which have resulted from other causes than
acute pharyngitis seldom require such radical methods of treatment.
In every case, the cause must be found and consistent treatment
given. In my experience, the radical method of treatment has not been
found necessary in more than twenty per cent of cases of chronic
otitis media. In the other cases the treatment consists of removing
sources of focal infection (about forty per cent) and normalizing
nasopharyngeal reflexes by osteopathic and local treatment (about forty
per cent). In all cases, the treatment must be complete. To remove
thoroughly all obstruction from the epipharynx and leave a source of
focal infection in the tonsils will accomplish little, or to remove
carefully all pharyngeal obstruction and all sources of focal infection
will not restore normal functions of the middle ear structures if the
osteopathic lesions and gastro-intestinal perversions are neglected.
Surgery in itself, even though carefully and thoroughly done, is not
efficient treatment and this is why the medical specialists fail in
this disease. After the necessary surgery has been done, then normal
tone must be restored to the various tissues involved. Normal reflex
mechanisms must be reestablished and this can be done by thorough and
efficient osteopathic corrective work and the proper local treatment
directly to the structures affected.